About CASE: In August 2021, the Colorado Department of Public Health and Environment partnered with Children’s Hospital Colorado to start the Colorado Antimicrobial Stewardship Endeavor (CASE). CASE includes physicians, pharmacists, and epidemiologists who provide mentorship and resources to Colorado hospitals that may be new to antibiotic stewardship.
Through a series of workshops and one-on-one consultations, CASE members support hospital antibiotic stewardship programs to:
- Develop evidence-based actions to improve antibiotic use,
- Develop procedures to track and monitor antibiotic use,
- Extend antibiotic stewardship activities to pediatric patients,
- Have a forum for discussion among antibiotic stewards in community hospitals.
CASE also seeks to provide resources such as treatment guidelines, support for reporting antibiotic use to the National Healthcare Safety Network (NHSN), and links to evidence-based guidelines and tools.
About the website: This website will offer updates on CASE activities and links to evidence-based resources to improve antibiotic use in all Colorado hospitals.
- Michael J Bozzella DO MS (CASE Lead): firstname.lastname@example.org
- Lynda Saignaphone (CDPHE Contact): email@example.com
CASE workshops schedule:
- January 21, 2022 - Stewardship in Colorado part 1 MJB v2 (presentation slides)
- February 25, 2022 - Stewardship in Colorado part 2 v2 (presentation slides)
- April 22, 2022 - Stewardship in Colorado part 3 (presentation slides)
- June 24, 2022
CASE 1-on-1 ASP Consult Sessions
Individuals from our two teams work together to troubleshoot difficulties and help develop plans for improving your stewardship program over a 30-60 min session. These sessions are tailored to your specific needs and situations. If you are interested in scheduling a session or learning more, please contact Michael Bozzella or Lynda Saignaphone (emails above).
Antibiotic stewardship programs optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Adverse events include side effects, inadequate treatment of infections, and the creation of antibiotic resistant bacteria and fungi. CDC developed the Core Elements of Hospital Antibiotic Stewardship Programs as a framework for hospitals to build upon. The Core Elements also serve as a standard for quality care. Learn more about the Core Elements and related resources below. *
CDC’s Core Elements of Hospital Antibiotic Stewardship Programs
Additional Implementation Resources
- CDC. Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals
- National Quality Forum. National Quality Partners Playbooks
- Children's Hospital Colorado Professional Resources
- The Society for Healthcare Epidemiology of America. Practical Implementation of Antibiotic Stewardship (textbook for purchase)
- Stenehjem et al. Antibiotic Stewardship in Small Hospitals: Barriers and Potential Solutions. Clin Infect Dis 2007.
- WHO. Antimicrobial stewardship interventions: a practical guide (2021)
Antibiotic Stewardship in Colorado Hospitals
- CDPHE report: Antibiotic Stewardship in Colorado Hospitals
*CASE seeks to help hospitals implement activities within the Core Elements framework that are most likely to improve antibiotic use in hospitals.
Facility-specific clinical practice guidelines serve as a gold standard for antibiotic selection and duration of therapy and are a foundation for antibiotic stewardship program actions. Recommendations should be based on national guidelines but should reflect hospital treatment preferences based on local susceptibilities, treatment options, and patient mix. Facility-specific guidelines should address common indications for antibiotic use like community-acquired pneumonia, urinary tract infection, skin and soft tissue infection, intra-abdominal infection, and surgical prophylaxis.
- Infectious Diseases Society of America Practice Guidelines
- American Academy of Pediatrics Practice Guidelines
- Sanford Guide (subscription required)
- American Academy of Pediatrics Red Book (subscription required)
Facility-specific guidelines and clinical pathways (examples)
Because hospitals may have limited resources for antibiotic stewardship, it is important for antimicrobial stewardship programs to prioritize actions that are most likely to improve antibiotic use. Some actions that are recommended by evidence-based guidelines include:
- Prospective audit with feedback: an external review of antibiotic therapy by a member of the antibiotic stewardship team, accompanied by suggestions to optimize use, at some point after the agent has been prescribed.
- Handshake stewardship: rounding-based review of antibiotic therapies by the antibiotic stewardship team with in-person suggestions to optimize use.
- Preauthorization: prescribers gain approval prior to the use of certain antibiotics designated by the antibiotic stewardship team.
Learn more about these and other recommended pharmacy, microbiology, nursing, and technology actions that are proven to improve antibiotic use in hospitals.
Priority Actions to Improve Antibiotic Use
- Infectious Diseases Society of America. Implementing an Antibiotic Stewardship Program
- Tinker et al. Interventions to Optimize Antimicrobial Stewardship. Antimicrobial Stewardship & Healthcare Epidemiology.
Additional Resources for Prioritization
- Doernberg et al. Essential Resources and Strategies for Antibiotic Stewardship Programs in the Acute Care Setting. Clin Infect Dis 2018.
- Hurst et al. Handshake Stewardship A Highly Effective Rounding-based Antimicrobial Optimization Service. Pediatric Infectious Disease Journal 2016.
- Tamma et al. What Is the More Effective Antibiotic Stewardship Intervention: Preprescription Authorization or Postprescription Review With Feedback? Clin Infect Dis 2017.
- Reed et al. Impact of Formulary Restriction with Prior Authorization by an Antimicrobial Stewardship Program. Virulence 2013.
- Anderson et al. Feasibility of Core Antimicrobial Stewardship Interventions in Community Hospitals. JAMA Network Open 2019.
- Stenehjem et al. Impact of Implementing Antibiotic Stewardship Programs in 15 Small Hospitals: A Cluster-Randomized Intervention. Clin Infect Dis 2018.
Measurement is critical to identify opportunities for improvement and to assess the impact of interventions. Measurement of antibiotic stewardship interventions may involve evaluation of both processes and outcomes. A priority metric for antibiotic use is antibiotic days of therapy (DOT). A DOT is the total number of days for which a specific antibiotic is given. It is usually expressed as a rate per 1,000 patient-days or days present and can be stratified by location of prescription or antibiotic class. Antibiotic use data can also be used to provide feedback to prescribers. The National Healthcare Safety Network (NHSN) offers an Antibiotic Use and Resistance Module that allows hospitals to track antibiotic DOT in their facility against national benchmarks and submit data to inform public health priorities. Learn more about tracking antibiotic use from the resources below.
Measures of Antibiotic Use
- Benic et al. Metrics for quantifying antibiotic use in the hospital setting: results from a systematic review and international multidisciplinary consensus procedure. J. Antimicrob Chemother 2018.
- Moehring et al. Expert Consensus on Metrics to Assess the Impact of Patient-Level Antimicrobial Stewardship Interventions in Acute-Care Settings. Clin Infect Dis 2017.
- Polk et al. Measurement of Adult Antibacterial Drug Use in 130 US Hospitals: Comparison of Defined Daily Dose and Days of Therapy. Clin Infect Dis 2007.
National Healthcare Safety Network
- CDC, National Healthcare Safety Network. Antimicrobial Use and Resistance (AUR) Options.
- CDC, National Healthcare Safety Network. FAQ: Antimicrobial Use (AU) Option
- CDC, National Healthcare Safety Network. AU Case Examples
- CDC, National Healthcare Safety Network. Vendors that have Passed the AU SDS Validation
Antibiotic resistance is a public health threat and a key motivator of antibiotic stewardship. Tracking antibiotic resistance can inform public health priorities, provide targets for antibiotic stewardship in hospitals, and give clinicians information necessary to prescribe appropriate antibiotics for patients. See resources for tracking antibiotic resistance below.
Antibiotic Resistance Data and Reports
- CDC. 2019 AR Threats Report
- CDPHE. HAI Data
- Children’s Hospital Colorado. Bugs and Drugs Handbook 2020
- Children’s Hospital Colorado. Bug Watch
Microbiology and Antibiograms
- Clinical and Laboratory Standards Institute. M100 Performance Standards for Antimicrobial Susceptibility Testing
- Clinical and Laboratory Standards Institute. M39 Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data, 5th Edition. (purchase required).
- Hindler et al. Analysis and Presentation of Cumulative Antibiograms: A New Consensus Guideline from the Clinical and Laboratory Standards Institute. Clin Infect Dis 2007.
- Moehring et al. Challenges in Preparation of Cumulative Antibiogram Reports for Community Hospitals. J Clin Micro 2015.
National Healthcare Safety Network
Please see select resources below designed to boost the expertise of antibiotic stewardship program staff and provide education to prescribers and patients.
- CDC. Antibiotic Prescribing and Use
- CDC. Training on Antibiotic Stewardship
- Making a Difference in Infectious Diseases. Antimicrobial Stewardship Programs
- Society of Infectious Diseases Pharmacists. Antimicrobial Stewardship Certificate
- Stanford Medicine. Stanford Antimicrobial Stewardship Online CME Courses
- University of Washington, interactive Medical Training Resources (iMTR). Dialogue Around Respiratory Illness Treatment
- New York State Department of Health. Educating Patients About Antibiotic Use. (Youtube video)
- Goldstein et al. Approaches to Modifying the Behavior of Clinicians Who Are Noncompliant With Antimicrobial Stewardship Program Guidelines. Clin Infect Dis 2016.